Taking Antidepressants During Pregnancy

Mother's Mental Health, Medication Safety Important Issues

Sad pregnant woman sitting on sofa against wall
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Deciding whether to start or continue taking an antidepressant if you become pregnant can be a difficult decision. Expectant parents often worry that certain exposures during pregnancy will cause birth defects. Prospective parents may wonder if medications will negatively affect their attempts to conceive.  

Studies have indicated that many medications—including antidepressants—may affect a developing fetus. However, research has also demonstrated that maternal depression can negatively impact fetal development. These effects may even have lasting consequences that stretch into childhood and beyond.

Deciding whether to take antidepressants during pregnancy is not a decision you need to make alone. Armed with the facts about each type of antidepressant, you can discuss the pros and cons of your choice with your doctor and mental health care provider. 

Pregnancy, Depression, and Antidepressants  

In 2019, the Centers for Disease Control and Prevention (CDC) published a report on the rate of depression in women giving birth in a hospital between 2000-2015. According to data, the rate of depression in 2015 was seven times higher than it had been in 2000.  

Previous research published in 2007 had indicated that the rate of depression among pregnant women was between 12-15%. The rate of depression in U.S. women overall is around 10%, according to the CDC. 

According to a 2012 report from the CDC, depression in pregnancy often goes undiagnosed. Of all people who are diagnosed with depression (whether they are pregnant or not) only about half receive treatment. Approximately 39% of pregnant people are prescribed medication to treat depression.  

Pregnancy causes a cascade of physiological and psychological changes which may increase a person’s risk of depression. This risk may even extend after the birth of a child and contribute to symptoms of postpartum depression.  

The biological stress of pregnancy, such as shifting hormones, can also change how the brain and body respond to antidepressants. These changes can impact everything from how the medications are metabolized and absorbed, to how they are eliminated. The ramifications may affect both the pregnant parent and the developing fetus. 

Pregnancy may affect how well an antidepressant works or the side effects it causes. Even if someone does not wish to stop taking an antidepressant while they are pregnant, they may need to adjust the dose. 

Antidepressants can cross the placenta and enter the amniotic fluid. The medications also pass into breastmilk, meaning exposure can continues after a baby is born through breastfeeding.  

Many studies have suggested that antidepressants can impact fetal development, but the evidence has not been conclusive. Research on the effects of antidepressants in pregnancy is limited largely due to ethical restrictions.  

People who are pregnant, fetuses, and newborns cannot be directly subjected to the type of testing or experimentation that would be necessary to provide more definitive proof of the medication’s effects. 

Based on what researchers do understand about the mechanisms of both pregnancy and pharmaceutical treatments for depression, it’s likely that many factors determine what, if any, effect antidepressants have. 

Each class of antidepressant medication carries its own set of risks. Everyone who is taking an antidepressant needs to be informed of and understand these risks. If you are pregnant or planning to conceive, it’s important to discuss your individual risk factors with your doctor.

The FDA categorizes and labels all drugs based on research about their safety, including how safe they are to take during pregnancy. Your doctor may choose to prescribe a drug the FDA has not categorized as being completely safe to take during pregnancy if the benefits of the medication outweigh the risk.  

SSRIs 

Selective serotonin reuptake inhibitors (SSRIs) are one of the most commonly prescribed classes of antidepressant medications. Popular SSRIs include: 

SSRIs are among the newer classes of antidepressants available. Consequently, there is more research about their safety. However, SSRIs are not without risk.  

The research on SSRIs in pregnancy has been largely mixed. Some studies have linked specific medications to an increased risk of miscarriage and birth defects, but subsequent studies failed to confirm these findings.  

For example, a 2007 study indicated that taking Paxil in the first trimester of pregnancy might be linked to a higher risk of congenital heart abnormalities. However, later studies showed that heart defects were found just as often in babies whose mothers had not taken antidepressants.  

In addition to maternal and fetal health, researchers have also evaluated whether taking an antidepressant during pregnancy affects newborn health.

Poor neonatal adaptation (PNA) or neonatal adaptation syndrome is a recognized and treatable condition that occurs in approximately 10-30% of newborns who were exposed to SSRIs or SNRIs in utero. 

When they are no longer being exposed to low levels of the antidepressant, newborns may develop respiratory and/or neurological problems like those seen in babies withdrawing from exposure to illicit drugs and alcohol. 

However, unlike the consequences of conditions like fetal alcohol syndrome, babies with poor neonatal adaptation usually respond well to treatment and get better on their own within a week after birth. Research has suggested that other factors, such as whether infants were breast or formula-fed after birth, may also influence the risk for PNA

Researchers aren’t sure why some newborns develop the syndrome while others do not. It likely depends on many individual factors (such as drug metabolism) specific to both the infant and the mother.  

SNRIs 

Serotonin-norepinephrine reuptake inhibitors (SNRIs) block the reuptake of both serotonin and another neurotransmitter called norepinephrine. Common SNRIs include: 

While some research has claimed an association between SSRIs and SNRIs and preterm birth, other studies have not supported these claims.  

The risk of rare conditions, such as persistent pulmonary hypertension, may be increased in newborns who were exposed to antidepressants in the womb, but the research is not conclusive. The overall risk of a baby developing the form of high blood pressure is incredibly small (<1%).  

TCAs 

Tricyclic antidepressants (TCAs) are the oldest class of antidepressants. TCAs work by blocking neurotransmitters and other receptors in the brain.

Although TCAs have been in use for a long time, they aren't prescribed as often today. These medications tend to have more side effects than newer antidepressants.

The most commonly prescribed TCAs include: 

  • Elavil (amitriptyline)  
  • Tofranil (imipramine)  
  • Pamelor (nortriptyline)  
  • Anafranil (clomipramine)  

Elavil is one commonly prescribed TCA and may also be given to people who get migraines. As with the other TCAs, research on using Elavil during pregnancy is limited. The small number of studies has not definitively linked the medication to specific outcomes for people who are pregnant, or fetuses exposed to the drug in the womb. 

Several studies have evaluated large numbers of pregnant women taking TCAs or other antidepressants and proposed a link between taking the medications early in pregnancy and certain congenital malformations. However, the authors note that their research did not account for other factors that could affect fetal development, like smoking cigarettes and using alcohol.  

MAOIs 

Monoamine oxidase inhibitors (MAOIs) work by breaking down neurotransmitters like dopamine and serotonin. Like TCAs, antidepressants in the MAIO class tend to have a lot of side effects and can interact with food, drinks, and other drugs.

Popular MAOIs include: 

  • Nardil (phenelzine) 
  • Emsam (selegiline) 
  • Marplan (isocarboxazid) 
  • Parnate (tranylcypromine) 

There has not been much research on MAOIs and pregnancy, partly because this class of antidepressants is not prescribed as often as newer antidepressants.

2017 case report published in the journal Reproductive Toxicology noted fetal malformations in the two pregnancies of a woman taking high doses of MAOIs. Both pregnancies resulted in fetal abnormalities, one of which was severe enough to result in stillbirth. The second infant was born with severe physical and neurological disabilities.

The authors of the paper speculated that the high dose of MAOIs contributed to outcomes of the pregnancies, but it was not clear if (or how) the medications caused the specific malformations. Additional factors may have contributed, such as the other medications the woman had taken during her pregnancy and the parents' ages (both were over 40). The family also declined to undergo testing to investigate a genetic cause for birth defects.  

Research on the potential risk of Nardil (one of the more commonly prescribed MAOIs) on a developing fetus is limited. The FDA label states that health care providers need to weigh the potential risks of Nardil against the benefits when prescribing the medication for people who are pregnant. This recommendation is consistent with the other MAOI antidepressants as well as medications in other classes.  

Atypical Antidepressants 

There are a few other medications that can be prescribed “off-label” to treat depression. Since they don’t neatly fit into one of the other categories, these drugs are referred to as atypical antidepressants/antipsychotics.  

While they are in the same category, the medications work in different ways and are often used to treat mental health conditions other than depression, such as bipolar disorder, schizophrenia, and attention-deficient hyperactivity disorder (ADHD). Some of the medications may also be prescribed to treat chronic pain and irritable bowel syndrome (both of which can co-occur with depression). 

Medications prescribed as atypical antidepressants include: 

The drugs within this class may be classified into subcategories based on how they work. For example, Wellbutrin is also classified as a norepinephrine and dopamine reuptake inhibitor (NDRI). 

Risperdal, Seroquel, Latuda, and Zyprexa are considered atypical antipsychotics. These drugs were developed to have fewer side effects than older antipsychotics and work by altering the levels of dopamine in the brain. This can help control symptoms such as hallucinations and paranoia in people with schizophrenia.

Due to the effect on dopamine and other neurotransmitters, atypical antipsychotics may also be helpful for people with severe depression who have not responded to other medications.

Researchers are also investigating other medications used to treat depression. For example, the CDC has led many studies on the effect of prescription and over-the-counter medications on pregnancy and fetal development as part of its Treating for Two initiative.

Most classes of antidepressants were evaluated in the research, including popular atypical antidepressants, such as Wellbutrin. A 2010 study indicated that taking Wellbutrin during early pregnancy was associated with an increased risk of fetal heart defects. However, researchers noted that the overall risk for those defects was small and concluded that more research was needed to establish Wellbutrin as a potential cause.

Another popular atypical antidepressant, Abilify, has also been the subject of research. A 2018 review of the literature concluded that if someone is taking Abilify before they become pregnant (and the drug has effectively managed their symptoms), health care providers should weigh the potential risks of continuing it against the risks of discontinuation.  

As with other drugs in this class, research about the potential risk of miscarriage, preterm birth, neonatal withdrawal symptoms, birth defects, and the potential for developmental delays is limited and, in some cases, nonexistent.  

Natural Treatments for Depression 

There are also non-prescription or alternative treatments for depression, such as St. John’s wort. Research hasn't established a significant difference in the risk of specific effects on the developing fetus (such as congenital malformations) when taking St. John's wort during pregnancy compared to antidepressants.

However, anyone planning to use St. John's wort needs to be aware of potential interactions. For example, taking St. John's wort with medications, supplements, or foods containing 5-hydroxytryptophan (5-HTP), L-tryptophan, or SAMe, can increase your risk for developing serotonin syndrome.

As with medications, ask your doctor about taking a nutritional supplement or herbal remedy if you are pregnant or breastfeeding.

For information on specific medications or alternative treatments, the Mother-to-Baby exposure database, maintained by the Organization of Teratology Information Specialists (OTIS), can be a helpful resource. The fact sheets created by the non-profit summarize the available research on the use of prescription medications and herbal supplements during pregnancy. 

The Risk of Untreated Depression 

While you will want to consider the risks associated with taking an antidepressant if you are pregnant, it's important to remember that untreated depression also carries risks.

Discontinuing an antidepressant puts you at risk for a relapse of your depression symptoms. The risk may be greater when you are pregnant and right after you give birth.  

Do not discontinue your antidepressant without talking to your doctor or mental health care provider. Unless they direct you to, do not abruptly stop taking your medication. Withdrawing from antidepressants can cause side effects and pregnancy may intensify these symptoms.

Pregnancy was once believed to provide some protection against depression due to shifting hormones, but research has not supported this theory. In fact, the opposite may be true: some research has shown that depression in either parent can affect the health of a child.  

Many studies have demonstrated that maternal stress during pregnancy can negatively affect fetal development and may influence the later behavior and emotional wellbeing of the child. 

The physical and emotional stressors of pregnancy can contribute to or worsen feelings of depression. The symptoms of depression can affect how well a person can take care of their needs. This includes everything from practicing overall self-care to pregnancy-specific care such as prenatal appointments.  

People with depression may also be more likely to use substances to cope with their symptoms. The risks associated with drinking alcohol and using illicit drugs during pregnancy are well-established. Substance use during pregnancy can have serious long-term consequences for parents and children.  

Eating well, getting enough sleep, staying physically active, and avoiding drugs and alcohol benefit everyone's wellbeing, but these considerations are especially important for expectant parents. The demands of pregnancy are felt in the mind as well as the body, so a healthy pregnancy requires taking care of your physical and mental health.  

A Word from Verywell 

Taking antidepressants during pregnancy and letting depression go untreated both present potential risks to mothers and infants. If you are trying to decide whether to stop taking your antidepressant, talk to your doctor or therapist. They can help you look at the most recent and relevant research, as well as consider your individual risk factors. This information will prepare you to make an informed decision. If you decide to stop taking your antidepressant medication while you are pregnant, you need to have a solid support system in place and strategies to help you cope with depression symptoms.

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